Taking Care: An Ombudsman Investigation Into The Care Provided To Margaret Warholm

Posted on May 13, 2015

Today, Ombudsman Mary McFadyen’s report titled Taking Care: An Ombudsman investigation into the care provided to Margaret Warholm while a resident at the Santa Maria Senior Citizens Home was tabled in the Legislature. The report, which includes 19 recommendations, is in response to a request from the Minister of Health to investigate the circumstances surrounding the care Margaret Warholm (Margaret) received at Santa Maria Senior Citizens Home (Santa Maria).

McFadyen said that families put a lot of trust in long-term care facilities: “At a minimum, families expect that their loved ones will be safe, clean and properly fed.” She found several instances where the care Margaret received met neither the Ministry of Health’s Program Guidelines for Special-care Homes (the Guidelines) nor Santa Maria’s own policies and procedures. These instances included the way her bedsores were managed, ensuring she had adequate nutrition and hydration, following up on changes in her weight, ensuring safe lifts and transfers, and managing her pain.

The report states that neither the Ministry of Health (the Ministry), nor the Regina Qu’Appelle Health Region (the Region) is making sure that the Ministry’s standards, as described in the Guidelines, are being met and applied consistently across the Region and in facilities throughout the province. McFadyen said, “All three levels of Saskatchewan’s long-term care system need to work collaboratively to establish clear performance expectations and hold one another accountable for meeting those expectations.” She also asked the Ministry to publicly report on whether each long-term care home in the province is meeting the
Ministry’s Guidelines.

McFadyen also found problems with the way Santa Maria responded to the concerns Margaret’s family raised. She made recommendations about Santa Maria’s concern-handling process and recommended that the Ministry’s Guidelines include more details about concern handling and appeals processes. She also recommended improvements to employer-staff relationships at Santa Maria.

Since the investigation started in November, McFadyen’s Office received 89 complaints about the quality of long-term care from all over the province. These complaints raised a number of issues that, in McFadyen’s view, point to a system under strain. While her office stayed focused on Margaret’s case, she took note of these additional issues, such as possible changes in residents’ needs, the staffing levels and staffing mix in long-term care homes, and whether residents are receiving enough care hours. She recommended that the Ministry of Health, in consultation with the health regions and other stakeholders look at these and other factors that may be affecting the quality of care, develop a long-term care strategy to address them, and make this strategy public.

McFadyen acknowledged the openness and frankness that Margaret’s family showed in sharing their story and thanked all the families and staff who contacted her Office. She said that each of the other complaints will be addressed appropriately and that several individual investigations are already underway. The report is available at www.ombudsman.sk.ca. The Ombudsman is an independent officer of the Legislative Assembly who operates under The Ombudsman Act, 2012. Her Office promotes and protects fairness and integrity in the design and delivery of government services.